Clarifire Conversations

November 02, 2018

Preparation is Key for Joint Commission Surveys

Nearly 21,000 U.S. healthcare organizations and programs are accredited and certified by The Joint Commission, making it a recognized symbol of quality nationwide.  It’s their vision that providers deliver safe, quality healthcare at the best value for all.  They determine this through regular, unannounced accreditation surveys1. Think the comprehensiveness of a final exam with a pop quiz schedule.  How do you cram for that?  You don’t.  You plan!

Joint Commission Visit

What Not To Do

It has been observed by surveyors that organizations who keep their staff prepared for survey related activities have a better on-site experience2. So how do you plan for such a task?  You start by understanding what you shouldn’t do.  Becker’s Hospital Review published an article with 5 mistakes to avoid with Joint Commission surveys3.  Here’s what our clients tell us are the top three items on that list.

  1. Lack of Preparation
    • Planning is the key to a successful visit.  If you fail to plan, then you should plan to fail.
  2. Absence of a Safety Culture
    • The focus of the Joint Commission is patient safety and quality of care. Culture breeds action.  Top down oversight and management of the organization’s safety culture is needed for success.
  3. Insufficient Performance Improvement Plan
    • Having a plan in place is crucial as it indicates to the surveyors how well a hospital identifies and corrects deficiencies

What To Do

With the proper preparation, a successful on-site visit is possible.  Here are a few tips that we have found with our clients that made their visits a success.


  • Develop a process for maintaining a continuous readiness plan.
  • Determine a mechanism for tracking your process. Workflow helps with compliance.
  • Create a culture of preparedness and communicate the importance.
  • Make it an ongoing priority. Practice you plan to ensure you’re ready for the big day.
  • Develop action plans for noncompliance. As healthcare evolves, continuous improvement is important.


  • Create a team to oversee accountability and results.
  • Conduct consistent meetings with leadership for progress reports.
  • Understand and communicate regulatory updates and changes.
  • Review and interpret survey/audit results/
  • Measure and provide analysis of results to staff, creating transparency.
  • Propose changes for improvement based on findings.


  • Create a plan for training and continuous education for your staff.
  • Educate your staff on the mission and vision of The Joint Commission. It’s important for them to understand the standards that apply to their job and department.
  • Create and implement mock surveys for staff to complete on a regular basis. Familiarity with the process makes it easier when it’s show time!
  • Ongoing continuing education for staff cannot be overdone. Knowledge is power and important for success.


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Reducing HAIs

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Tammy Bourassa

Tammy Bourassa leads the business account management team at Clarifire. She came to Clarifire with over 15 years of experience in selling and supporting client software solutions within the healthcare industry. Her industry knowledge ranges from pre hospital/EMS care to inpatient and rehabilitation care. Tammy has successfully led various sales, account management and operational teams. When asked, she said she really enjoys growing business by building relationships. "It's so much fun to work with all the flavors of people and to help solve their issues." 




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